Surgical treatment of early ovarian cancer with compartmental resection of regional lymphatic network and indocyanine-green-guided targeted compartmental lymphadenectomy (TCL, paraaortic part)

Whether pelvic and para-aortic lymphadenectomy is of therapeutic benefit in advanced ovarian cancer will remain unclear until the publication of the Arbeitsgemeinschaft Gynäkologische Onkologie lymphadenectomy in ovarian neoplasms (AGO LION) trial. In early ovarian cancer, however, lymphadenectomy seems mandatory for diagnostic and also therapeutic reasons. Complete systematic lymphadenectomy is accompanied by morbidity which may be reduced by sentinel node biopsy already established for several solid tumors. In ovarian cancer there are 2 main pathways in lymphatic drainage: along the ovarian vessels to the para-aortic nodes and the uterine vessels to the iliac lymph compartments. Following injection of radioactive dye into the ovarian ligaments this could be confirmed suggesting that there is bidirectional flow at this level of the ovarian and uterine lymphatic pathways. Indocyanine-green-guided (ICG) injection to the uterine corpus seems to be equally effective in labelling the "uterine Müllerian" and the "ovarian mesonephric" lymphatic drainage of the ovary. This technique was applied and will be outlined in the video showing the procedure with respect to the para-aortic lymphatic drainage. Isolated sentinel node biopsy and tumor excision will not resect the organ compartment together with its super-ordinated draining lymphatic system at risk. Thus, the authors suggest to remove the malignancy together with its draining lymphatic vessels and at least the first 2 sentinel nodes in each channel en bloc; we propose to analyze this procedure consistent with the ontogenetic approach with respect to diagnostic accuracy and loco-regional control. This could potentially avoid most of systematic lymphadenectomies in early ovarian cancer.